Inspection on 10/03/06 for Bellevue Court

This inspection was carried out on 10th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Bellevue Court 30/01/09

Bellevue Court 12/08/08

Bellevue Court 25/09/07

Bellevue Court 30/01/07

Bellevue Court 30/10/06

Bellevue Court 02/11/05

Bellevue Court 13/12/04

Bellevue Court 09/08/04

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Bellevue Court (Highfield Care Homes No 2 Limited) Bellevue Court Woodcross Street Woodcross Wolverhampton West Midlands WV14 9RT Lead Inspector Rosalind Dennis Unannounced Inspection 10th March 2006 11:00 X10029.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V286914.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People and Care Homes for Adults 18 – 65*. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V286914.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Bellevue Court (Highfield Care Homes No 2 Limited) Bellevue Court Woodcross Street Woodcross Wolverhampton West Midlands WV14 9RT 01902 662166 01902 6722300 Address Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Southern Cross Care Homes No 2 Limited Mrs Gail Emma Goddard Care Home 68 Category(ies) of Dementia (38), Mental disorder, excluding registration, with number learning disability or dementia (30) of places Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V286914.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 2nd November 2005 Brief Description of the Service: Bellevue Court is registered with the Commission For Social care Commission to provide care for adults and older persons with a mental illness and/or dementia. The home has three floors with a lift and stairs providing access between floors. Generally older persons reside on the ground and upper floors and younger adults or individuals with more complex mental health reside on the middle floor. Bellevue Court is located on the borders of Wolverhampton and Dudley, with local shops and a bus stop close by. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V286914.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector arrived unannounced at 11.00am and the inspection lasted for just over 4 hours. During that time the inspector spoke with residents on the middle floor, observed records and spoke with the manager and staff. The focus of this inspection was to review the progress made by the home since the last inspection and to review outstanding “key standards”. What the service does well: What has improved since the last inspection? What they could do better: No new requirements were made at this inspection. The home is continuing with its refurbishment plan to enhance the living accommodation. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V286914.R01.S.doc Version 5.1 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V286914.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V286914.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards not assessed on this occasion. EVIDENCE: The intended outcomes for Standards 3 and 4 were assessed at the previous inspection of this service and were not reviewed on this occasion. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V286914.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service Users, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards to be inspected at least once during a 12 month period JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 8 The care planning and risk assessment processes provide staff with the information they need to satisfactorily meet resident’s needs. EVIDENCE: Resident’s files that were checked on the middle floor showed that potential risk areas for individual residents have now been identified and documented in the form of a risk assessment. Care plans and “clients progress” sheets were observed to be up to date. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V286914.R01.S.doc Version 5.1 Page 10 All files checked showed that resident’s general and mental health care needs are kept under review, with staff seeking appropriate specialist advice when necessary. Since the last inspection the manager has commenced auditing medication practices and observation of this comprehensive audit provides confirmation that improvements have occurred. The medication treatment room was not observed on this occasion. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V286914.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service Users have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14 and 15 The home provides meals that offer variety and cater for different nutritional needs. Staff at Bellevue Court assist residents to exercise choice as far as possible and according to their differing capabilities. EVIDENCE: Individual discussion with four residents on middle floor evidenced that they are generally happy with the service provided by the home. All confirmed that choices are offered although two residents commented that they were disappointed with the recent introduction of “House Rules”. The manager Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V286914.R01.S.doc Version 5.1 Page 12 confirmed that these rules had been introduced to provide some structure to the day and observation of minutes from weekly residents meetings confirmed that a discussion had been held with residents prior to introducing these changes. Other residents and staff commented positively regarding the improvements to the daily routine. The home currently uses a 4 weekly rotational menu system and observation of these menus demonstrates that a varied and satisfactory diet is offered. However two residents commented that they were “bored” with the current choices on offer, these comments were acknowledged by the manager who discussed potential changes that are intended to be made to the menus. The manager discussed that it is intended to develop the kitchenette area on the middle floor so that residents can be enabled to prepare their own snacks, which will also enhance their independence. Throughout the inspection residents from the middle floor were observed to come and go respectfully during the day, and discussions with residents confirmed that their visitors are welcomed. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V286914.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service Users feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 19 The arrangements for the protection of residents from abuse is satisfactory. The home has a complaints system that ensures that concerns are listened to and acted upon. EVIDENCE: A full complaints procedure is available within the home. The manager maintains a record of any complaints received by the home and this record was observed to include action taken to address the complaint and the outcome. Residents reported that they would notify the manager or other senior staff if they were unhappy with any aspects of the home or care provision. The manager has a good knowledge of adult protection processes and procedures and training records checked at the last inspection evidenced that staff have received training in adult protection/abuse awareness. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V286914.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Standards not assessed on this occasion. EVIDENCE: The intended outcomes for Standards 19 and 26 were assessed at the previous inspection of this service and were not reviewed on this occasion. Observation of refurbishment plans evidenced that improvements are being made to the environment in order to provide residents with a more comfortable place to live. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V286914.R01.S.doc Version 5.1 Page 15 Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V286914.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 The home has a robust recruitment procedure in place that protects residents from the employment of inappropriate staff. EVIDENCE: Two staff files that were observed during the inspection showed that the home operates a robust recruitment procedure. The staff files were well organised and the required pre-employment checks for staff had been completed. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V286914.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 and 35. The home is continually monitoring and reviewing processes to ensure that residents receive a good range of quality services. EVIDENCE: Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V286914.R01.S.doc Version 5.1 Page 18 The manager is a registered nurse with a good range of supporting qualifications, skills and experience and since the last inspection has completed the registration process with CSCI. Staff members that were spoken with confirmed that they feel well supported by the manager and that good training opportunities exist within the home. The home operates a comprehensive process of auditing quality and practice, which includes catering, health and safety, recruitment and medication. The audit scores provide confirmation that improvements have occurred at the home. Suggestions and comments forms are readily available in the Reception area of the home and completed forms are sent direct to the company head office. The manager is aware of the need to commence a quality assurance system based on seeking the views of residents and their representatives. Senior management conduct monthly, unannounced visits of the home and a copy of this report is sent through to CSCI. Observation of records demonstrates that resident’s financial interests are safeguarded and the home maintains accurate records of all financial transactions. Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V286914.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X 6 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 X 20 X 21 X 22 X 23 X 24 X 25 X 26 X STAFFING Standard No Score 27 X 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No Score 31 3 32 X 33 3 34 X 35 3 36 X 37 X 38 x Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V286914.R01.S.doc Version 5.1 Page 20 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 8. Standard OP19 Regulation 23 (2)(d)16 (2)(j) Requirement The registered person must ensure that the refurbishment plan for the home is completed. (Timescale from November 2005 inspection). Timescale for action 01/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 4. Refer to Standard OP38 Good Practice Recommendations The registered person is strongly advised to clarify that training in fitting of bed rails has been provided for staff, that bed rails are included in the maintenance programme and determines who takes responsibility for the fitting of bed rails in the absence of the maintenance person. (In process of being achieved). Bellevue Court (Highfield Care Homes No 2 Limited) DS0000039462.V286914.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Wolverhampton Area Office 2nd Floor St. Davids Court Union Street Wolverhampton WV1 3JE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. 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